Malpractice Certificate
Change of Address
General Liability (Office) Declaration Page
General Liability Additional Insured Request (Please fax the request from the additional insured to our office 480-657-8505)

Fill –In Doctor request form (Locum Tenens)
Copy of Malpractice Renewal Invoice
New Doctor application for associate Dr.’s
Premium Financing Specialists auto debit form

Rate for Increasing limits of liability to:

$1M/$3M
$500/$1M
$250/$750
$200/$600

Additional information and comments: